title: Contrast ultrasound in hepatocellular carcinoma at a tertiary liver center: First Indian experience.
abstract: OBJECTIVE
  To assess the role of contrast enhanced ultrasonography in evaluation of hepatocellular carcinoma (HCC) at the first Indian tertiary liver center.
  
  
  METHODS
  Retrospective analysis of contrast enhanced ultrasound (CEUS) examinations over 24 mo for diagnosis, surveillance, characterization and follow up of 50 patients in the context of HCC was performed. The source and indication of referrals, change in referral rate, accuracy and usefulness of CEUS in a tertiary liver center equipped with a 64 slice dual energy computer tomography (CT) and 3 tesla magnetic resonance imaging (MRI) were studied. Sonovue (BR1, Bracco, Italy, a second generation contrast agent) was used for contrast US studies. Contrast enhanced CT/MRI or both were performed in all patients. The findings were taken as a baseline reference and correlation was done with respect to contrast US. Contrast enhanced MRI was performed using hepatocyte specific gadobenate dimeglumine (Gd-BOPTA). Iomeron (400 mg; w/v) was used for dynamic CT examinations.
  
  
  RESULTS
  About 20 (40%) of the examinations were referred from clinicians for characterization of a mass from previous imaging. About 15 (30%) were performed for surveillance in chronic liver disease; 5 (10%) examinations were performed for monitoring lesions after radiofrequency ablation (RFA); 3 (6%) were post trans-arterial chemo-embolization (TACE) assessments and 3 (6%) were patients with h/o iodinated contrast allergy. About 2 (4%) were performed on hemodynamically unstable patients in the intensive care with raised alpha fetoprotein and 2 (4%) patients were claustrophobic. The number of patients referred from clinicians steadily increased from 12 in the first 12 mo of the study to 38 in the last 12 mo. CEUS was able to diagnose 88% of positive cases of HCC as per reference standards. In the surveillance group, specificity was 53.3% vs 100% by CT/MRI. Post RFA and TACE specificity of lesion characterization by CEUS was 100% in single/large mass assessment, similar to CT/MRI. For non HCC lesions such as regenerative and dysplastic nodules, the specificity was 50% vs 90% by CT/MRI. The positive role of CEUS in imaging spectrum of HCC included a provisional urgent diagnosis of an incidentally detected mass. It further led to a decrease in time for further management. A confident diagnosis on CEUS was possible in cases of characterization of an indeterminate mass, in situations where the patient was unfit for CT/MRI, was allergic to iodinated contrast or had claustrophobia, etc. CEUS was also cost effective, radiation free and an easy modality for monitoring post RFA or TACE lesions.
  
  
  CONCLUSIONS
  CEUS is a valuable augmentation to the practice of ultrasonography, and an irreplaceable modality for confounding cases and interpretation of indeterminate lesions in imaging of HCC.
authors.affiliation: Shalini Thapar Laroia, Simranjeet Singh Bawa, Department of Radiodiagnosis, Institute of Liver and Biliary Sciences, New Delhi 110070, India.
authors.forename: Shalini Thapar
authors.initials: ST
authors.lastname: Laroia
authors.forename: Simranjeet Singh
authors.initials: SS
authors.lastname: Bawa
authors.forename: Deepak
authors.initials: D
authors.lastname: Jain
authors.forename: Amar
authors.initials: A
authors.lastname: Mukund
authors.forename: Shiv
authors.initials: S
authors.lastname: Sarin
keywords: Contrast ultrasound; Dynamic contrast enhanced magnetic resonance imaging; Hepatocellular carcinoma; Tertiary liver care; Triple phase contrast-enhanced computed tomography